Operative Treatment of Flat- 
Foot by Supramalleolar 
Osteotomy. 
WILLY MEYER, M. D. 
BX 
REPRINTED FROM 
Ett Neto ¥oirtt fttetncal journal 
for May 1890. Reprinted from the New YorTc Medical Journal 
for May 1890. 
OPERATIVE TREATMENT OF FLAT-FOOT 
BY SUPRAMALLEOLAR OSTEOTOMY * 
WILLY MEYEE, M. D. 
The great progress of orthopaedic surgery in regard to 
the treatment of the static deformities of the lower extremi- 
ties dates from the time that bloody operations, rendered 
safe hy antisepsis, have been added to our orthopaedic re- 
sources. For each of the well-known deformities—such as 
genu valgum and varum, talipes varo-equinus and talipes 
plano-valgus—a great number of operations have been pro- 
posed and are still performed. Especially for the cure of 
the two last-mentioned troubles a great variety of operations 
exist. This proves that no operation has as yet been found 
which can be safely relied upon in its ultimate results. 
There are even authorities who reject all operative in- 
terference in these deformities of the foot, and profess to be 
able to cure even severe cases of this class by repeated forci- 
ble reposition under narcosis and retention in a portative 
plaster-of-Paris or silicate-of-potassium splint. 
Still others object even to this treatment, as far as the 
flat-foot is concerned, on the ground “that such retention 
would interfere with the movements of the foot and prevent 
* Read before the New York Surgical Society, March 12, 1890. 2 
OPERATIVE TREATMENT OF FLAT-FOOT 
the exercises for strengthening the muscles, on which we 
must place our main reliance.” * They hope to cure flat- 
foot by means of shoes, braces, gymnastic exercises of great 
variety, massage, etc. Old cases, with permanent changes 
in the bones, can only be improved in this way. 
Of course no objection could be made to these non-op- 
erative methods if it were true that a real cure could often 
be effected by them and without recurrence of the deform- 
ity after cessation of the treatment. Such methods should 
indeed be first tried in all cases of flat-foot where the de- 
formity is still easily reducible by manipulations. But in 
more advanced cases, where the deformity has become rigid, 
where the astragalus has slipped forward, downward, and 
inward from the os calcis and the scaphoid also has been dis- 
placed downward, where the shape of the bones has been 
permanently changed, this treatment will take a long time 
before a cure is effected. And even then the ultimate re- 
sult will be doubtful. 
Now, there are not in many cities hospitals and dispen- 
saries where orthopaedic machines and braces are accurately 
constructed on scientific principles and supplied for a mod- 
erate price. A good, reliable shoe-maker is not so easily 
found. Not every patient is willing to undergo a long-con- 
tinued treatment or is able to pay for it, though the charges 
may be trifling. Why, may be asked, has osteotomy been 
almost everywhere adopted in the treatment of genu valgum 
and genu varum, which deformities can, to a great extent at 
least, also be cured by orthopaedic apparatus in the course of 
months ? Why, then, should flat-foot alone be excluded from 
the benefits of operative treatment ? If there is a safe operation 
and all these operations are safe under careful antiseptic 
* Royal Whitman, Observations on Seventy-five Cases of Flat-foot. 
Transactions of the American Orthopaedic Association, vol. i, p. 129, 
1889. BY SUPRAMALLEOLAR OSTEOTOMY. 
3 
precautions—which promises to accomplish a cure in weeks 
what others can only do in months, it should be sufficiently 
tried. And if its results are found by many to be good and 
permanent, it should be added to the multiple means which 
are now at the disposal of orthopaedic surgery. Of course, 
no surgeon would think of operating on the flat-foot of a 
pregnant woman or on that of a fat man, because in the one 
case the confinement, in the other the reduction of weight, 
would remove the complaint without need of treatment; 
none would ever, at least not at present, attack the pes valgus 
of a rickety child. But in the treatment of the poor work- 
ing class, where, in bakers’ boys, grocers’ boys, and butchers’ 
boys, in messengers and waiters, flat-foot is such a very com- 
mon disease and in so many instances help is applied for 
only when the deformity offers firm resistance to its reduc- 
tion, a shorter treatment ought to be welcome. 
Before describing the operation mentioned in the title, 
a short review of the various operative procedures which 
until date have been devised and tried in the treatment of 
flat-foot, and the results achieved with them, may be of 
some interest. 
1. So far as a careful perusal of the literature shows, 
C. H. Golding-Bird, of London, was the first to operate for 
flat-foot, in 1878.* He operated on four patients—on three 
in 1878 and on one in 1879—between twelve and seventeen 
years of age. In two cases the scaphoid bone alone was 
removed, and in two that bone together with the head of 
the astragalus. In one of these Golding-Bird sawed subcu- 
taneously across the whole tarsus, besides removing the 
scaphoid. The results were uniformly good ; all the patients 
were cured of pain, but in only one case was the arch really 
restored. Richard Davy, of London, performed the same 
operation on two patients, fourteen and seventeen years old 
* Guy’s Hosp. Rep., 1882, p. 457; Lancet, 1889, i, p. 677. 4 
OPERATIVE TREATMENT OF FLAT-FOOT 
respectively, in 1887 and 1888.* The result was satisfac- 
tory in each case, so far as walking power was concerned. 
“ The patients, having been prevented from gaining their 
living, could again pursue their duties as milkman and 
newsboy.” 
2. In 1884 A. Ogston, of Aberdeen, published his opera- 
tion for the cure of flat-foot, f He believes that the deformity 
is caused by relaxation of all the articulations of the foot, espe- 
cially that between the scaphoid and the head of the astraga- 
lus, and subsequent alteration of shape in the bones of Cho- 
part’s joints. He considers these two points as being “ the 
key to the disease and its successful operative treatment.” 
He therefore attacks Chopart’s joint with the intention of 
restoring it in its normal position and thereby rectifying the 
faulty position of the foot. The usual careful preparations 
having been carried out, he cut down on the astragalo- 
scaphoid articulation, chiseled off the cartilaginous surfaces, 
and, after restoring the two bones to position, fixed them 
together with fine ivory pegs, which were left in the wound. 
Careful catgut suture, antiseptic dressing, and a few turns 
of plaster-of-Paris bandage outside the latter, finished the 
operation. This operation was performed seventeen times 
in ten patients (until January 14, 1884), usually on both 
feet in one sitting. In one case Chopart’s joint was pegged 
as well as that between the scaphoid and internal cunei- 
form, because its movement seemed unusually free. The 
wounds healed by primary union. The patients were per- 
mitted to walk a little at the end of two months, but, as a 
rule, they should not do so until three months have elapsed. 
All patients were benefited by the operation and satisfied 
* On Excision of the Scaphoid Bone for the Relief of Confirmed 
Flat-foot. Lancet, 1889, i, p. 675. 
f Alexander Ogston, On Flat-foot and its Cure by Operation. The 
Lancet, January 26, 1884. BY SUPRAMALLEOLAR OSTEOTOMY. 
5 
with the result, even at considerable periods after the opera- 
tion. They resumed their former occupation. Objective 
examination proved the plantar arch to be restored to per- 
fection in a number of cases; in the others it always was 
much improved. 
At the meeting of the British Medical Association, 
1888, Ogston presented a roll of forty-seven cases, similar- 
ly operated, with the same encouraging results. 
3. W. Stokes,* of Dublin, removed a wedge-shaped piece 
of bone from the enlarged head and neck of the astragalus 
in a boy fourteen years old. He called his operation astrag- 
aloid osteotomy. By adducting and supinating the foot, 
the restoration of the arch was perfect; six months later 
the author learned by report that the boy “ was able to 
walk, run, and play about as well as any other healthy boy 
of his age.” 
4. Two years ago Weinlechner,f of Yienna, excised the 
astragalus in one side for the radical cure of flat-foot. At 
first the leg was shortened for half an inch ; this was out- 
grown later. After some time the tibio-tarsal articulation 
was rather stiff; mobility in Chopart’s joint more satisfac- 
tory. The patient could more easily walk and stand on the 
foot operated upon than on the other. 
A great variety of operations has been published last 
year. 
5. A. W. Hare J modified Ogston’s operation and tried it 
in one case. To avoid the introduction of an ivory support 
he cut the bony surfaces of the astragalo-scaphoid joint in 
a zigzag line, and then replaced the two bones, allowing the 
projecting upper two thirds of the head of the astragalus 
to rest upon a horizontal artificial plane of the scaphoid. 
* Annals of Surgery, October, 1885. 
f Wien. med. Blatter, 1888, x. 
\ Lancet, Nov. 9, 1889, p. 953. 6 
OPERATIVE TREATMENT OF FLAT-FOOT 
“ Tbe bones were held firmly in tbeir new relationship to one 
another, and it was at once seen that the arch of the foot 
was restored.” Seven weeks after the operation “ the pa- 
tient could walk easily and without pain ; he was able to 
return to his usual employment, and has continued to im- 
prove since.” 
6. A. M. Phelps,* of New York, recently performed an 
operation for fiat-foot “ which consisted in making an in- 
cision across the sole of the foot, and through this incision 
the muscles and fascia were hooked up, cut apart, shortened, 
and again stitched together. The skin was also shortened. 
The object of the operation was to shorten the girders 
which held up the arch,” A preliminary treatment of 
about two to three weeks is necessary in order to mobilize 
the displaced rigid arch. 
7. At the last meeting of the German Surgical Society 
at Berlin, April, 1889, F. Trendelenburg, of Bonn,f commu- 
nicated his experience with supramalleolar osteotomy in the 
radical treatment of flat-foot. Having seen good results 
with this operation in correcting traumatic talipes valgus, 
a position which was the result of a neglected and unreduced 
Pott’s fracture, it occurred to him to try the same method 
for the idiopathic flat-foot. His calculation was this: The 
cause of the great functional disorder and the excruciating 
pain in traumatic flat-foot is the displacement of the line 
of gravity by the alteration of the longitudinal axis of the 
leg. The latter does not cross the sole of the foot in its 
median line, as is the case in the normal foot, but in a 
point nearer to its inner border, and thus the weight of 
the body is also brought to bear inside of its normal posi- 
tion. On account of the eversion of the foot in some cases 
* Transactions of the American Orthopaedic Association, vol. i, 1889, 
p. 137. 
f Archiv f. klin. Chirurgie, Bd. xxxix, 4. Heft, p. 751. BY SUPRAMALLEOLAR OSTEOTOMY. 
7 
the line of gravity meets the inner border of the sole itself; 
sometimes, if the deviation is very marked, not even this, 
hut a point of the ground entirely outside of and inwardly 
from the sole. This condition may be best studied in ex- 
amining such an extremity from its posterior side. The 
foot being in this abnormal position, the tarsal ligaments 
will be stretched with each step ; the foot becomes everted 
(talipes valgus). Walking and standing tend to increase 
the deformity, and consequently the patient’s troubles. 
In the idiopathic flat foot the condition is very similar. 
The most striking symptom is, of course, the flattened arch. 
But in all advanced cases, where the deformity is irreduci- 
ble and the foot in the everted or valgus position, the 
changed relation between axis of leg and plantar arch is 
the same as in a case of badly treated Pott’s fracture. The 
axis nearly passes the internal border of the sole, the in- 
ternal malleolus is markedly prominent, the external nearly 
invisible. 
Now, if in traumatic flat-foot tibia and fibula are cut 
across with the chisel right above the malleoli, the deform- 
ity can easily be corrected and the foot so placed “ as to 
transmit the weight of the body,” if the patient walks 
again, “through the tarsus in an oblique direction—that is, 
through the cuboid instead of the scaphoid bone.” This 
is, as Phelps stated (loc. cit.), the object of treatment of 
flat-foot. 
With the experience of this operation it was, of course, 
very tempting for Trendelenburg to try supramalleolar os- 
teotomy also for the radical cure of idiopathic flat-foot. He 
performed the operation seven times in five patients between 
sixteen and forty years of age (until April, 1889), and was 
astonished to see the remarkable success in all of them. 
The arch was restored and the displacement of leg and foot 
at once removed; the difficulty and pain in walking and 8 
OPERATIVE TREATMENT OF FLAT-FOOT. 
standing had fully or nearly disappeared. A sixteen-year- 
old boy who had been successfully operated upon on both 
sides in one sitting four months previous was presented to 
the society. 
At the same meeting Eugen Hahn * stated that he had 
adopted a very similar plan of operation for flat-foot inde- 
pendently of Trendelenburg. He performed osteotomy on 
the tibia only, and also deems it important to cut the bone 
right above the malleolus. But, to avoid opening of the 
tibio-tarsal joint, he incises the skin a little farther above 
than Trendelenburg. He had operated five times on three 
patients (up to April, 1889). One of the patients was 
cured, the second improved. In the third the operation 
rather aggravated the trouble. But this case was compli- 
cated, as the scaphoid bone formed a very marked promi- 
nence ; the inner border of the foot was convex, the outer 
concave (pes reflexus). Hahn proposes to add Ogston’s 
operation to osteotomy and reduction in such extreme 
cases. 
The way I came to try supramalleolar osteotomy for 
flat-foot is somewhat similar to that of Trendelenburg, al- 
though the idea did not originate with me. 
In April and May, 1889, two patients came under my 
care at the German Hospital who had been treated for 
Pott’s fracture somewhere else. In both a very marked 
valgus position of the foot resulted, which entirely dis- 
abled the men. I performed supramalleolar osteotomy of 
tibia and fibula and succeeded in easily reducing the foot. 
The result in both cases was perfect. One of the patients, 
a young man twenty years of age, was presented to 
this society some fourteen weeks ago (he is also here to- 
night). Position and use of the foot are fully restored. 
* Ctrlbl. f. Chir., 1889, Beilage, p. 108, and Verhandlungen d. 
deutsch. Gesellsch. f, Chir., Berlin, 1889, p. 81. BY SUPRAMALLEOLAR OSTEOTOMY. 
9 
The man can walk many miles a day without the slightest 
discomfort. (Patient presented at the meeting.) 1 have 
been unsuccessful in finding the second patient. But I have 
learned that he resumed his former occupation—peddling; 
certainly sufficient proof for the good and permanent result 
of the operation performed on him. 
After the experience of these two traumatic cases, I 
read in the report of the last Surgical Congress Trendelen- 
burg’s proposition to adopt supramalleolar osteotomy for 
the radical cure of flat-foot. This struck me as an emi- 
nently clever suggestion—so much the more as the success 
achieved with this method by Trendelenburg, even in far- 
advanced cases and older patients,* is rather remarkable. 
In estimating the value of the operation it is interesting 
to notice that it removes the cause of the flat-foot accord- 
ing to either of the two main theories which have been 
given for its aetiology. The one, advanced in an excellent 
paper by Royal Whitman,| read before the last meeting of 
the American Orthopaedic Association, and in a similar 
manner by A. Lorenz, J a few years ago, claims that in the 
normal foot the weight of the body falls upon the os calcis 
at a point internal to its base, and thus tends to roll it over 
toward the inside, presenting an inclined plane for the sup- 
port of the leg. In consequence of this displacement the 
astragalus has a tendency to slip downward and inward on 
the articular facets of the os calcis. According to Lorenz, 
this only occurs under increased weight. Normal muscles 
and ligaments prevent any excessive displacement, and after 
each step restore the bones to their previous position; the 
displacement is only temporary. But if the strength of the 
* Trendelenburg, he. cit. Tafel xv, A. B. 
X Die Lehre vom erworbenen Plattfuss, Stuttgart, 1884, Otrlbl. f. 
Cbir., 1884, p. 315. 
f Loc. cit. 10 
OPERATIVE TREATMENT OF FLAT-FOOT 
supporting muscles is overtaxed, they get tired (Henke). 
Then the ligaments alone must support the arch of the foot, 
and thus bear the entire strain, although they are really in- 
tended to act only as auxiliaries to the muscles.* It will 
not be long before the ligaments become stretched, espe- 
cially the inferior calcaneo-scaphoid ligament, and hence the 
bones permanently displaced. 
How far rickety softness of the bones comes into con- 
sideration in regard to the development of flat-foot (Koenig) 
can not be decided yet to-day. 
The other theory is that of von Meyer, f It is founded 
on a number of careful post-mortem examinations. Ac- 
cording to this theory, the inferior calcaneo-scaphoid liga- 
ment is not stretched, the arch of the foot not flattened, the 
line drawn from the middle of the os calcis to the head of 
the first metatarsal bone not materially lengthened. He 
attributes the deformity to an inward displacement of the 
arch, and with it of the whole foot, due to an exaggerated 
rotation of the astragalus. This latter is caused by an in- 
crease in the weight to be supported, faulty attitudes as- 
sumed in standing and walking, especially the latter, with 
turning out of the toes, wearing improper shoes, and so on. 
Now, whether an abnormal persistence of the normal 
displacement of the astragalus on the os calcis is the origi- 
nal cause of flat-foot, or whether the entire foot is simply 
turned over in the sense of pronation, without being ma- 
terially altered in its shape, supramalleolar osteotomy is in- 
dicated by both theories to be a rational operation. With- 
out interfering with the bones or joints or soft tissues of 
the tarsus in any way, the result of the operation is, that 
the articular facets of the os calcis are placed in a plane ob- 
f Ursache u. Mechanismus d. Entstehung des erworbenen Plattfusses, 
Jena, 1883 ; Ctrlbl. f. Chir., 1883, No. 18, p. 284. 
* Koenig, Lebrbuch d. speciell. Chir., IY. Auflage, Bd. iii, p. 640. BY SUPRAMALLEOLAR OSTEOTOMY. 
11 
lique externally. Then, when the weight is brought upon 
the foot in walking and the os calcis should still turn in- 
ward, these facets could only be brought to a horizontal 
plane, and so the astragalus can no longer slip downward 
and. inward. Thus the good results of the operation would 
be perfectly in accord with the first-mentioned theory of 
flat-foot. 
Again, the operation puts the entire foot into such a 
position that the patient must walk on its outer border, as 
is the case in the normally shaped foot. Thus the second 
theory, that of von Meyer, which explains the deformity by 
the total rotation inward of the foot, is also met by the 
operation. 
My own two cases are the following: 
Case I.—E. K., twenty-four years old, baker, entered my serv- 
ice at the German Hospital on November 23, 1889. Two years 
and a half ago be bad noticed the first pain in his feet. Daring 
work he had always walked in slippers. The dorsum of the foot 
was usually swollen at night. Two months before the patient 
was admitted to the hospital the pain was so excruciating, even 
right after getting up, that he was obliged to quit work. He 
then applied Jor help at the German Dispensary, and was attend- 
ed there as an out-patient for a short while. When the usual 
treatment was found not to give any material benefit, the patient 
was sent up to the hospital for operation through the courtesy 
of Dr. E. Bacbmann, surgeon to the German Dispensary. On 
examination, the two feet presented the condition shown in 
the two casts which have been kindly taken by Dr. F. E. Son- 
dern, of the house staff (Fig. 1). By a misunderstanding, the 
casts do not include the malleoli and lower third of the leg. 
But, nevertheless, it can be well observed that the arch of 
both feet has entirely collapsed, that the inner side of the foot 
runs in a line parallel to the ground, and is everywhere in con- 
tact with it. The sole of the foot left the imprint shown in 
Fig. 2, made from a photograph of the plaster of-Paris traces 
kindly taken by Dr. Henry Macdonald from the casts shown in OPERATIVE TREATMENT OF FLAT-FOOT 
Fig. 1. The protuberance on the inner side of Chopart’s joint 
is not very marked. There is also present the condition of a 
Fig. 1. 
“ stiff toe ”to some extent. The case appearing a suitable 
one for radical treatment, I resolved to perform supramalleolar 
osteotomy. 
Fig. 2. BY SUPRAMALLEOLAR OSTEOTOMY. 
13 
In doing this I followed the rules laid down by Trendelen- 
burg. After careful carrying out of the usual preparations, an 
incision, half an inch Jong, was made down to the fibula, about 
two inches above the tip of the malleolus, the foot being turned 
inwardly by an assistant and resting on a sand-bag, which was 
covered by a moist antiseptic towel. Then the chisel was in- 
troduced into the wound, turned 90°, and the bone cut across. 
This wound being covered by an aseptic sponge, tlie leg was 
placed with its outer side on the operating-table, and the same 
operation performed on the tibia at about an equal distance 
from the tip of the internal malleolus as had been chosen on the 
fibula. By using a heavy, sharp, and broad steel chisel, as rec- 
ommended by Macewen, this operation was done in a very few 
minutes. The rest of the tibia, which had not been divided, 
was then broken by forcibly pressing the foot into a pronounced 
valgus position. By these means the danger of wounding the 
Fig. 3. 
posterior tibial artery was avoided. Now the foot could be 
easily reduced. It was very interesting to observe how the 
restoration of the arch of the instep was at once absolutely 14 
OPERATIVE TREATMENT OF FLAT-FOOT 
perfect. The same operation having been performed on the 
other leg, the wounds were dressed and both lower extremities 
put up in a plaster-of-Paris splint, which was strengthened by 
long interposed strips of thin wood, and ran up from the toes 
to the middle of the thigh. The knee joint was flexed to about 
145° in order to relax the gastrocnemii, and special care taken 
to hold the foot in a somewhat overcorrected position, so that 
the line drawn alongside the spine of the tibia did not meet the 
first interosseous space as it does in the normal foot, the planta 
facing the ground, but the last one between the fourth and fifth 
Pig. 4. 
toe. There was no reaction after the operation. The tempera- 
ture never rose above 100°. Some pain daring the first twenty- 
four hours was easily controlled by a hypodermic of morphine. 
When the first dressing was changed on the thirty-fifth day, 
the wounds were found to be closed, except one, which was still BY SUPRAMALLEOLAR OSTEOTOMY. 
15 
superficially granulating. It rapidly healed under an ointment 
dressing. At the end of the sixth week the patient got up on 
crutches. I kept him in the hospital until now to watch the 
result, the time since then being used by application of massage, 
foot baths, and exercises. 
The result as it presents itself to-day—three months and a 
half after the operation—is best seen in these two casts, which 
have been taken ten days ago and include the lower half of the 
leg, and in the photographs kindly taken by Dr. F. H. Zitz, of 
the house staff, last week. We notice : 
Fig. 5. 
LeftSide.—Perfect position of the foot; arch fully restored 
(Fig. 6, trace); standing and walking cause no pain. There is 
no stiffness in the tibio-tarsal joint; only the extreme plantar 
flexion is still somewhat impeded, but gradually improving. 
The patient says that he can walk and stand on that foot all 16 
OPERATIVE TREATMENT OF FLAT-FOOT 
day long without the slightest inconvenience. The former ex- 
cruciating pain, which rendered the patient a perfect invalid, 
has entirely disappeared. 
Eight Side.—Plantar arch restored to perfection (Fig. 6, 
trace). Slight inward rotation of the foot, evidently caused by 
improper fixation of the upper fragment by the nurse, who held 
it during hardening of the gypsum. [ln applying the splint 
with the help of one assistant, I had the foot held in the re- 
duced position by the second assistant—this being the principal 
part of the operation—and the leg by the hands of a nurse.] 
Standing and walking painless in the morning. After a few 
hours, exercise causes some pain and tires out. But the pain is 
different from that before the operation, undoubtedly due to the 
Fig. 6. 
somewhat twisted course of the muscles. The constant im- 
provement of the patient gives hope that the cure will, never- 
theless, soon be complete.* 
Case lI.—P. 8., butcher, twenty years old, was admitted to 
* When the patient left the hospital, on March 21st, he stated that 
all his pain had ceased. He could walk for about an hour without 
trouble and was about to resume work. BY SUPRAMALLEOLAR OSTEOTOMY. 
17 
the German Hospital on December 10, 1889. Two years ago 
he noticed the first pain in his right foot. He had to work very 
hard, carrying heavy weights and standing all day long. He 
got easily tired. The pain steadily increased, especially below 
the external malleolus, and also slightly attacked the other foot. 
Six weeks before entering the hospital he was obliged to give 
up his situation. As long as he can remember, the feet were 
peculiarly shaped. The casts, also taken by Dr. F. E. Sondern, 
demonstrate this nicely. There is an adduction and slight su- 
pination in Ohopart’s joint, as found in talipes varus, which 
nearly makes it seem as if there were no flat-foot at all. But 
examination of the right foot revealed the dislocation of the 
head of the astragalus, forming a marked prominence below 
the internal malleolus. In correcting the adduction of the fore- 
foot the flattened arch becomes very evident. The diagnosis 
was rather difficult. The left foot is less affected, but also pain- 
ful. Patient of slender build, size six feet, that of the feet 
eleven inches. As the patient suffered so much, I resolved to 
operate on him. Supramalleolar osteotomy was performed on 
December 13th in the same manner as above described. It was 
also followed by no reaction. First change of dressing on 
January 14th, five weeks and a half after the operation ; wounds 
closed. On January 23d patient walked for the first time on 
crutches. He left the hospital February 23d. Although the 
peculiar combination of the original deformity with flat-foot 
did not make the case a very suitable one for operation, the re- 
sult as it presents itself to-day, exactly three months after the 
operation, is very satisfactory. The arch of the foot, though 
not really flattened before the operation on account of the ad- 
duction and supination of the anterior portion of the foot, is 
very marked. Patient walks several hours in laced shoes with 
the support of a cane. The pain below the outer ankle has left 
him. Only now and then a slight drawing sensation is noticed. 
The walk improves rapidly. It is not yet steady when the pa- 
tient is barefooted. Patient will soon be able to resume his 
former occupation. (The two patients were presented at the 
meeting.*) 
* At the time of correcting the proof the patient walked easily 
without any support. 18 
OPERATIVE TREATMENT OF FLAT-FOOT 
In criticising the result of supramalleolar osteotomy in 
the operative treatment of flat-foot, as demonstrated in my 
two patients, it does not need a trained eye, Mr. President, 
to see, as far as the position of the feet is concerned, that 
it could be improved in two of the four feet operated upon. 
It certainly would be still more perfect in these two cases 
also if I had changed the splint between the tenth and 
twelfth day after the operation and corrected the position, 
as Trendelenburg recommends to do. This is no doubt an 
essential feature in the after-treatment. As my experience 
in the two cases of traumatic flat-foot had told me that the 
position maintained by the first splint was such as to need 
very little or no correction at all, I tried to simplify the 
after-treatment and effect the cure under the first dressing. 
But I think this was wrong. Slight mistakes may occur 
during the application of the first splint, and may be easily 
corrected if the splint is changed and the position revised. 
In my two cases the position of the feet is overcorrected. 
I did that purposely. I intended to find out whether the 
application of a brace, to be worn later for a short while, in 
order to maintain the new position, as Trendelenburg has 
done, could thus be avoided. As it seems to me, after this 
rather small and short and insufficient experience, slight 
overcorrection and wearing a tight-laced shoe may make 
the application of a brace unnecessary and the after-treat- 
ment therewith more simple. If correction is overdone, 
there may result such an angular displacement of the frag- 
ments at the point of osteotomy as to nearly produce a 
traumatic talipes varus. 
The result, as shown in ray two cases until date, certainly 
tends to sustain Trendelenburg’s hope that supramalleolar 
osteotomy can cure flat-foot in a comparatively short time. 
The restoration of the arch, which is so perfect and sur- 
prisingly easy after the operation, seems to be permanent. BY SUPRAMALLEOLAR OSTEOTOMY. 
19 
Whether it will prove to be so eventually, after heavy work 
has been performed, is a question that the future must decide. 
But I think there is no reason to fear a relapse. Whether, 
further, it will always be necessary to operate on both bones 
or to perform osteotomy of the tibia only, as Hahn has done, 
still remains to be decided. How far the results of this 
treatment will reflect upon the theory of flat-foot is not 
easy to determine. It certainly shows, as I believe, that 
the change in transmitting the weight through the tarsus is 
the principal cause of all the trouble and pain the patient 
complains of. That the patients are entirely relieved of 
their previous constant pain by this operation is beyond 
doubt. 
Whether Ogston’s operation must be added now and 
then, as Hahn proposed, will depend upon each case. Per- 
haps it may be necessary or advisable in the extreme cases 
of talipes valgus. 
My own impression is that supramalleolar osteotomy, as 
proposed by Trendelenburg, is a valuable and important con- 
tribution to the many ways of curing flat-foot by operation 
—one which in course of time may perhaps prove to be the 
best of all. It seems to be worthy to be thoroughly tested 
by those who have a large material at their command. 
The following brief conclusions may with propriety be 
drawn: 
1, Supramalleolar osteotomy seems to be the most ra- 
tional operation for the radical cure of flat-foot, as its object 
is to correct the deformity without interfering with any of 
the tissues of the foot proper. It therefore deserves trial. 
2. In far-advanced cases (talipes valgus) it will most 
probably give a good result too, and may advantageously 
be combined with Ogston’s operation (Hahn), 
3. If osteotomy has been performed, the position of the 
foot can be easily corrected or overcorrected. 20 
OPERATIVE treatment of flat-foot. 
4. The tibia and fibula should be cut close to the tibio- 
tarsal joint and the latter not injured. 
5. As soon as the foot is pressed into a normal position 
it will be seen that the arch is completely restored. 
6. Between the tenth and twelfth days the splint should 
be renewed and the position of the foot re-examined, and, 
if necessary, definitely corrected. 
7. The patient may get up in about five to six weeks 
after the operation. 
8. A slight overcorrection may be advisable to guard 
against recurrence and the necessity of temporarily wear- 
ing a supporting brace. REASONS WHY 
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